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RULE §354.1415Vendor Requirements and Conditions for Participation

(a) In addition to the general requirements for contractors listed in Chapter 391, Purchase of Goods and Services by the Health and Human Services Agencies and Chapter 392, Procurements by the Health and Human Services Commission, care management companies must meet all of the following program requirements to be considered for a contract with the state. Entities who wish to contract with the Health and Human Services Commission (HHSC) to provide wellness program services must meet the following conditions:

  (1) Use HHSC-approved predictive modeling approaches to identify high-cost and high-risk populations;

  (2) Use approaches that are based on nationally recognized evidence-supported models, standards of care in the medical community and clinical outcomes;

  (3) Have collaborative healthcare practice models in place to include HHSC's contracted physicians, support service providers, and existing community resources;

  (4) Ensure that a recipient's primary care provider, and other appropriate specialty physicians, or registered nurses, advance practice nurses, or physician assistants become directly involved in the Texas Medicaid Wellness Program;

  (5) Ensure that providers serving as medical homes take an active role in helping clients or their caregivers make informed health-care decisions;

  (6) Use patient self-care management strategies, so that clients become informed and active participants in the management of their physical and mental health conditions and co-morbidities;

  (7) Provide client and provider educational materials that are culturally sensitive and appropriate to the targeted population;

  (8) Have process and outcome measurements, evaluations, and management systems that incorporate nationally recognized evidence-based clinical practice guidelines;

  (9) Have routine reporting processes that are proven to properly support wellness goals;

  (10) Provide access to 24 hour-a-day, seven days-per-week nurse consultation/triage line;

  (11) Provide coordination of client care during a transition period for clients that move from enrollment in one disease management or wellness program to another; and

  (12) Have the ability to guarantee program savings.

(b) The contracted Texas Medicaid Wellness Program vendor must provide at a minimum, the following services to eligible clients and participating providers:

  (1) Identify eligible clients utilizing predictive modeling and impactability scores and stratify them into severity levels for care management services;

  (2) Provide appropriate interventions that include, at a minimum, development and evaluation of an individual plan of care that:

    (A) Addresses the client's comprehensive health, behavioral, and social needs to ensure continuity of care, quality of care, and improvement of health status;

    (B) Assures and facilitates appropriate collaboration between the client's family and/or caregivers, health care providers, and community case managers; and

    (C) Links health care providers with allied health and social services agencies to facilitate access to necessary services. This includes, but is not limited to, medically necessary services such as pharmacy, mental health, equipment and supplies, rehabilitative therapies, and transportation or interpreter services.

  (3) Intensive outreach to difficult-to-serve clients, including home visits if the client does not have telephone service available, or has cognitive or physical difficulties that interfere with phone usage. The vendor must use effective, appropriate, and culturally sensitive methods to accomplish this service;

  (4) Enroll and engage eligible clients in the Texas Medicaid Wellness Program and track active acceptance, refusal to participate, complaints, levels of care and disenrollment information;

  (5) Facilitate the establishment of a medical home or primary care provider for clients;

  (6) Identify gaps between recommended prevention and treatment and actual care provided to clients. Assure that client's medical care follows nationally recognized evidence-based practice guidelines. Give providers feedback on differences between recommended treatment and actual care received by clients, including client adherence to their plan of care;

  (7) Assess client's adherence to prescribed medical care and instructions;

  (8) Assist client in accessing appropriate primary and preventive medical care;

  (9) Development and demonstration of educational and care management techniques by phone, written materials, and face to-face personal interaction;

  (10) Development and circulation of client educational materials that must be:

    (A) Written at the 5th grade reading level;

    (B) Available for clients who are blind, sight impaired, or have reading impairments; and

    (C) Provided in English, Spanish and the language of any other major population group identified by HHSC.

  (11) Educate eligible clients and/or their caregivers regarding the client's particular health care condition so that they will:

    (A) Become more effective in the management and self-care of their health problems/conditions;

    (B) Utilize appropriate resources needed to care for his or her problem(s);

    (C) Identify changes in his or her health condition and seek appropriate attention before reaching crisis levels; and

    (D) Become more compliant with medical recommendations.

  (12) Provide a 24 hour-a-day, seven day-a-week, toll-free nurse consultation and triage service that responds in a culturally sensitive manner to eligible clients and/or caregivers' questions;

  (13) Have English and Spanish-speaking nurses, with other languages available through a translation or interpretation service. The vendor also must have nurses who speak the languages of major population groups identified by HHSC;

  (14) Provide referrals for specialty, social and ancillary services through the use of a nurse consultation telephone line;

  (15) Maintain documentation of wellness services in the member file or care plan and distribute or provide to the primary care provider via an electronic provider portal or on a periodic basis if providers do not have electronic capabilities;

  (16) Develop and/or support a mechanism to receive timely notification of hospital admissions or emergency department visits of Texas Medicaid Wellness Program clients, and coordinate with hospitals to provide discharge planning services;

  (17) Provide care coordination support, revisions to client's plan of care as appropriate, and on-site visits when needed;

  (18) Provide coordination with behavioral health providers where the client has a behavioral health condition;

  (19) Develop a process to respond to client and provider complaints with HHSC oversight;

  (20) Provide intensive recruitment of providers (including specialists when warranted by the client's medical condition) to participate in the Texas Medicaid Wellness Program and serve as primary care providers, or as a medical home for eligible clients as needed;

  (21) Develop and offer provider education regarding specific evidence-based practice guidelines and improved practice management methods;

  (22) Ensure medical providers actively participate in the development of the eligible client's plan of care;

  (23) Implement a system for providers to request specific wellness interventions via referrals to the program;

  (24) Provide assistance in assuring necessary specialty care; and

  (25) Provide reports on client's health status changes to their participating primary care provider.

Source Note: The provisions of this §354.1415 adopted to be effective May 10, 2004, 29 TexReg 4447; amended to be effective February 20, 2005, 30 TexReg 666; amended to be effective September 1, 2007, 32 TexReg 1904; amended to be effective July 19, 2011, 36 TexReg 4555

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